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Hours on hold, limited appointments: Why California babies aren’t going to the doctor

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Hours on hold, limited appointments: Why California babies aren’t going to the doctor

Maria Mercado’s 5- and 7-year-old daughters haven’t been to the doctor for a check-up in two years. And it’s not for lack of trying.

Mercado, a factory worker in South Los Angeles, has called the pediatrician’s office over and over hoping to book an appointment for a well-child visit, only to be told there are no appointments available and to call back in a month. Sometimes, she waits on hold for an hour. Like more than half of children in California, Mercado’s daughters have Medi-Cal, the state’s health insurance program for low-income residents.

Her children are two years behind on their vaccinations. Mercado isn’t sure if they’re growing well, and they haven’t been screened for vision, hearing or developmental delays. Her older daughter has developed a stutter, and she worries the girl might need speech therapy.

“It is frustrating because as a mom, you want your kids to hit every milestone,” she said. “And if you see something’s going on and they’re not helping you, it’s like, what am I supposed to do at this point?”

Faye Holmes with 4-year-old sons Robbie, left, and JoJo, right, waits for a nurse to administer shots.

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(Gary Coronado / Los Angeles Times)

California — where 97% of children have health insurance — ranks 46th out of all 50 states and the District of Columbia for providing a preventive care visit for kids 5 and under, according to a 2022 federal government survey. A recent report card from Children Now, a nonprofit advocacy group, rated California a D on children’s access to preventive care, despite the state’s A- grade for ensuring children have coverage.

The majority of California’s youngest residents — including 1.4 million children ages 5 and under — rely on Medi-Cal, an infrastructure ill-equipped to serve them. The state has been criticized in two consecutive audits in the past five years for failing to hold Medi-Cal insurance plans accountable for providing the necessary preventive care to the children they are paid to cover.

In a written response to questions from The Times, the Department of Health Care Services, the state agency in charge of the Medi-Cal program, said “improving children’s preventive care is one of DHCS’ top priorities,” and that the agency has recently addressed most of the shortcomings identified in the audits.

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The department’s focus on the pandemic slowed action on the audit findings, the response said. State healthcare officials have since begun to more harshly fine plans that don’t provide adequate care and substantially boost payments to pediatricians to help increase access.

But information released publicly this month by the department suggests serious problems remain.

“In the whole scheme of the U.S. health system, I hate to say it, the youngest kids are always the ones that are overlooked,” said Dr. Alice Kuo, a pediatrician and health policy professor at UCLA.

According to state Medi-Cal data from 2021, the most recent year for which detailed data are available, and assessments from health experts, the impact is sobering:

  • 60% of babies did not get their recommended well-child visits in the first 15 months of life. Access was even worse for Black babies — 75% did not receive their recommended screenings. Children who do not attend their well-child visits are more likely to go to the emergency room and be hospitalized for illnesses like asthma.
  • 65% of 2-year-olds were not fully vaccinated, leaving them vulnerable to preventable diseases like measles and whooping cough.
  • Half of children did not receive a lead screening by their second birthday; families may not know if their homes or other environments are unsafe, which raises the potential for irreversible damage.
  • 71% of children did not receive their recommended developmental screening in their first three years. Without routine screenings, less than half of children with developmental or behavioral disorders are detected before kindergarten and miss out on early interventions.

“There’s a lot that happens in a well-child visit that keeps the child healthy in the immediate and the long term,” said Dr. Yasangi Jayasinha, a pediatrician with the Los Angeles County Department of Public Health. A doctor must ensure that a child is growing and developing normally, getting the proper nutrition, and help the family get plugged into other needed resources like food and housing assistance.

A baby drinks from a bottle.

Anthony Serrano’s mother, Alexia Peralta, spent months in limbo trying to get her son re-enrolled in Medi-Cal.

(Dania Maxwell / Los Angeles Times)

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“No state is perfect, but it is particularly concerning that California isn’t at least in the middle of the pack, given its focus on young children and the importance of early brain development,” said Elisabeth Wright Burak, who studies child health policy at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.

A growing problem

There are myriad reasons for California’s poor rates of preventive care for children, according to health experts across the state: a shortage of pediatricians who accept Medi-Cal, especially in rural parts of the state; transportation issues for families who don’t have a car; difficulties getting time off work to take a child to a doctor’s appointment; a byzantine Medi-Cal bureaucracy that makes coverage difficult to use for patients.

In 2019, a California State Auditor report found that less than half of children with Medi-Cal received their recommended preventive care. The audit blamed low reimbursement rates to Medi-Cal physicians, as well as poor state oversight, and gave the department a list of fixes.

Three years later, the auditor released a follow-up report, saying that the department had failed to fully implement eight of the 14 recommendations, including making sure directories of available providers are accurate and requiring health plans to address barriers to care.

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The 2022 report found access had grown even worse, a decline largely attributed to the pandemic. Just 42% of children in Medi-Cal received their recommended preventive care. An average of 2.9 million children were missing out on care each year.

For the youngest children the results were particularly troubling: 60% of 1-year-olds and 73% of 2-year-olds in Medi‑Cal did not receive the required number of preventive services.

Although federal law requires that families have access to primary care within 10 miles or 30 minutes of their home, the health department had issued more than 10,000 exceptions. In Monterey County, for example, a healthcare plan requires families to travel up to 58 miles to see a pediatrician.

The department has since implemented all but one of the recommendations it agreed to, and is in the process of overhauling the Medi-Cal program, the response said. This includes beginning to levy higher fines against Medi-Cal plans that do not provide recommended well-child visits, vaccinations and lead screenings to enough children.

A spokesperson for the state auditor’s office said the department has not proved that it has implemented three of the recommendations.

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A doctor looks at a child in his mother's lap.

Dr. Alice Kuo performs a well-child visit with 4-year-old patients Robbie, left, and JoJo, with help from their mother, Faye Holmes.

(Gary Coronado / Los Angeles Times)

This month, the department announced assessments and fines for 2022. While DHCS reported some progress on access to well-child visits, the plans continued to struggle overall, and the quality of children’s healthcare lagged behind measures for other types of care, including behavioral health and chronic disease management.

Only one plan met all of the minimum standards on children’s health: Community Health Group Partnership Plan in San Diego. Eighteen out of 25 plans were fined $25,000-$890,000 for poor performance, including for children’s health.

Long waits, long drives

Parents and advocates say getting care for children remains a daily challenge. About 11 million Californians live in a primary care shortage area, where a pediatrician can be difficult to find.

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“It’s most of the state, not just the Central Valley,” said Kathryn E. Phillips, an associate director at the California Health Care Foundation. California has not trained enough new doctors to meet the needs of the population, she said, and the current workforce is aging. In rural areas in particular, it can be difficult to recruit new pediatricians to join a practice.

Historically, Medi-Cal has paid doctors far less than other insurers, and the program has struggled to find enough willing to accept the rates. In 2021, for example, Medi-Cal paid $37 for a checkup with a toddler.

For the record:

2:27 p.m. Feb. 26, 2024An earlier version of this story incorrectly stated the name of pediatrician Eric Ball as Eric Bell.

“Medi-Cal patients basically don’t keep the lights on. You can’t make ends meet,” said Dr. Eric Ball, a pediatrician in Orange County. About a quarter of his patients have Medi-Cal, but the practice stays afloat because of payments from privately insured patients. That may change as the state has increased the Medi-Cal rates significantly this year, up to $116 for a toddler checkup.

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In Los Angeles, families often face long wait times to get an appointment with a Medi-Cal provider— 82% of children in the county did not receive a developmental screening in the first three years, 2020 state data showed.

At UCLA, Kuo said patients at her practice must book their well-child visits three to six months in advance. “We get patients coming from Palm Springs to UCLA because there’s no access.”

Cecilia Prillwitz drops her 7-year-old son at school.

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Many Californians — especially those with low incomes — can’t afford the costs or time to make such a long drive, especially for the multiple visits recommended each year for a baby or toddler. Medi-Cal provides a transportation benefit to members, but many families don’t know it exists or say it is difficult to arrange.

“Families are so stressed about housing. They’re stressed about the price of gas. The cost of living here is so high,” said Dr. Lisa Chamberlain, a professor of pediatrics at the Stanford School of Medicine. A doctor’s visit for a seemingly healthy child is “just not going to make it to the top of the list.”

Rosa Benito, 21, lives with her parents and five siblings in Thermal, a town in Riverside County, where the family works in agricultural fields. Getting her siblings to the doctor is a constant struggle.

“We just have my dad and his little gray car, ” she said. The family goes to a clinic in Moreno Valley, over an hour away, but it’s only open during the workday, and their farming jobs don’t offer sick time. Taking a child to the doctor means missing work, which they can’t afford.

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And since her parents lack documentation to be in the country legally, they’re scared of the long travel to the clinic for fear that they’ll be pulled over by Border Patrol. “It just turns into a bigger problem. The kids would be without a guardian,” explained Benito. Unless there’s an emergency, the trip often isn’t worth it.

Luz Gallegos of TODEC, a legal center in the Inland Empire serving immigrants and farmworkers, said many families stick with traditional “remedios” for their children and only bring them to the doctor for vaccines when it’s time to enroll in kindergarten. Some have lingering fears that using their child’s Medi-Cal benefits could affect their immigration status.

“Our families don’t think about prevention. They think about surviving.”

The Medi-Cal problem

While family challenges can play a role in missed visits, the state auditor found that the blame for California’s poor performance fell largely on the Medi-Cal program.

“By failing to prioritize implementing our recommendations, DHCS has… left certain children at risk of lifelong health consequences,” the auditors wrote in their 2022 report.

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Celia Valdez, director of health outreach and navigation at Maternal Child Health Access, an L.A. nonprofit that manages several social service programs, says they hear daily from families who don’t know how to navigate the Medi-Cal bureaucracy: missing insurance cards, an unexplained switch in their assigned pediatrician, coverage that is suddenly terminated. “People are lost, and by the time they get to someone who can help them, critical time has passed,” said Valdez.

A mother kisses her toddler.

Alexia Peralta kisses her son, Anthony Serrano, at their apartment in Hawthorne. A nonprofit helped her re-enroll Anthony in Medi-Cal after seven months in limbo.

(Dania Maxwell / Los Angeles Times)

For Alexia Peralta of Hawthorne, the problems started about two months after her son was born last year, when his Medi-Cal enrollment went awry. She tried to book his 4-month well-child visit and was told he didn’t have coverage; she would have to pay $145 for the visit — an impossible sum.

She spent seven months in limbo — calling Medi-Cal repeatedly, waiting on hold for hours to speak with someone in Spanish, only to be disconnected. Several times, she thought she’d solved the problem, only to get to the pediatrician’s office and be turned away.

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“I feel frustrated, mad and sad. I tried to get all these things for my child and got the run-around,” she said. He missed both his 4-month and 6-month vaccines.

Eventually, with the help of a home visitor from a Shields for Families program, a nonprofit in L.A., Peralta was able to get her son re-enrolled. At 15 months, he is still catching up on his vaccines.

Trying to fix the system

The health department said the challenges are not unique to California, and that the pandemic “resulted in large backlogs of children who needed to catch up on preventive services, a worsening crisis in the health care workforce, and limited additional capacity for pediatric services.”

In response, the department “has made historic investments and launched new initiatives” that “look to lift our youngest Californians and allow them to be healthy and to thrive.” This includes sending educational materials to families about recommended care, creating new contracts with Medi-Cal plans that more closely track children’s healthcare, and continuing to fine plans that fail to perform.

The state is also pumping money into the primary care workforce and is expanding residency and loan repayment programs. There are new Medi-Cal benefits to pay for doulas and community health workers, who can help patients navigate care, the response said.

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A toddler holds his grandmother's hands.

Sayra Peralta dances with her grandson, Anthony Serrano, as her daughter, Alexia Peralta, looks on.

(Dania Maxwell / Los Angeles Times)

“The big ship is slowly turning,” said Mike Odeh, senior director of health at Children Now, who serves in an advisory group for the department. “But I want to emphasize how big the ship is and how hard it is to turn, given that we have decades of plans not providing care for kids. Changing that is going to take a lot of work.”

Former State Sen. Richard Pan, who was chair of the Health Committee before terming out in 2022, said he is not yet convinced the department’s response to the audits has been adequate. The devil is in the details, he said — are the fines against plans high enough? And how many plans will end up complying?

“Give us the proof that it’s been fixed. Show us the data. Unfortunately, I’m not in a position now to hold hearings, but I think that’s the next follow through,” he said. “The buck should always stop at the state.”

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This article is part of The Times’ early childhood education initiative, focusing on the learning and development of California children from birth to age 5. For more information about the initiative and its philanthropic funders, go to latimes.com/earlyed.

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Column: Democrats show that they're no better than Trump in allowing politics to interfere with science

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Column: Democrats show that they're no better than Trump in allowing politics to interfere with science

Anyone who cares about the importance of science in the making of government policy had to be deeply dispirited by the hearing into the origins of COVID-19 staged by a Republican-led House subcommittee on May 1.

The sole witness at the hearing, and its target, was Peter Daszak, the head of EcoHealth Alliance, a nongovernmental organization tasked with overseeing international virus research funded by federal agencies.

It wasn’t just that the GOP majority used the occasion to promote the ignorant, imbecilic and 100% evidence-free notion that SARS-CoV-2, the virus that caused the COVID pandemic, originated in a Chinese laboratory, through work funded by the U.S. government, and overseen by EcoHealth.

Science is a myth-buster…Because of this, science has become a nuisance, even an enemy to some industries and many of the most powerful actors in the new attention economy.

— Science blogger Philipp Markolin

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It was that the Democratic minority showed itself to be complicit with the GOP attack on EcoHealth.

As I wrote at the time, the Democrats threw Daszak and by extension science itself under the bus: “Perhaps they hoped that by allowing Daszak to be drawn and quartered, they might persuade the Republicans to climb down from their evidence-free claims about government complicity in the pandemic’s origins.”

The Democrats’ craven and shameful performance hinted that EcoHealth’s government funding, which had been blocked by the Trump administration and restored, though delayed, under Biden, was pretty much doomed.

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On Wednesday, the bell tolled. EcoHealth received a notice from the Department of Health and Human Services, the parent agency of the NIH, that it was immediately suspending all funding to the organization and moving to “debar” it from federal funding going forward.

It’s impossible to overstate what a serious blow this is for EcoHealth and research into the origins of pathogens that could cause illness and death on a global scale — the central purpose of EcoHealth’s work.

The organization, which has operated with a budget of about $16 million, cannot receive a contract from any federal agency or even serve as a subcontractor of another awardee. All organizations with federal contracts that have affiliated with EcoHealth will be “carefully examined.”

EcoHealth says it will appeal the proposed debarment, as is its right. But that process could take years. In the meantime, the organization will be effectively out of money, and very likely out of business. The HHS action effectively turns one of the leading organizations in the quest to protect humankind from the next pandemic into a pariah, completely unjustifiably.

The debarment threat “will mean the demise of EcoHealth, one of the most scientifically productive and internationally respected groups conducting field surveillance for potential pandemic viruses,” says Gerald T. Keusch, a former associate director of international research at the NIH. “And that means our national security will be compromised.”

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Let’s be clear about what has happened here. EcoHealth has been made a scapegoat for the pandemic for partisan reasons. The process started with President Trump. At a news conference on April 17, 2020, a reporter from a right-wing organization mentioned that the NIH had given a $3.7-million grant to the Wuhan Institute of Virology. (Actually, the WIV grant, which was channeled from a larger EcoHealth grant, was only $600,000.)

Trump, sensing an opportunity to show a strong hand against China and advance his effort to blame the Chinese for the pandemic, responded: “We will end that grant very quickly.” The NIH terminated the grant one week later, prompting a backlash from the scientific community, including an open letter signed by 77 Nobel laureates who saw the action as a flagrantly partisan interference in government funding of scientific research.

The HHS inspector general found the termination to be “improper.” The NIH reinstated the grant, but immediately suspended it until EcoHealth met several conditions that were manifestly beyond its capability, as they involved its demanding information from the Chinese government that it had no right to receive. The grant was reinstated last year under Biden, but NIH bureaucrats, perhaps worried about their careers in a new Trump administration, continued to put administrative obstacles in the way of EcoHealth’s work.

The attacks on Daszak and his organization are simply instruments of the GOP project to pin blame for the pandemic on Anthony Fauci, one of the world’s most respected public health figures.

The context is a battle for the minds of uninformed and misinformed Americans over the origin of COVID-19. The hypothesis favored by most qualified virologists and epidemiologists is that the virus reached humans the way most viruses do — as spillovers from wildlife. The alternative hypothesis, for which absolutely not a speck of evidence has ever been presented, is that the virus emerged from a laboratory—specifically the Wuhan Institute of Virology in China, whether deliberately or through sloppy lab practices.

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The latter hypothesis was initially promoted by an anti-China cabal in the Trump-era State Department. Although they never produced any grounds for the conspiracy theory, it remains favored by anti-vaccine agitators and in the Republican anti-science camp. It has a certain appeal for uninformed people susceptible to sinister explanations of complicated, troubling events; but it’s not science.

Daszak calls the government actions “fundamentally unfair” and “based on a set of false assumptions about COVID-19 origins and on persistent mischaracterizations and misunderstandings of our research…Our work has been at the forefront of understanding pandemic risk for over two decades, and it’s a very cruel irony that because we knew that China was a potential hotspot for the next coronavirus pandemic, we’re now being targeted in a political backlash caused by exactly the type of pandemic we were concerned about preventing.”

An outgrowth of the lab-leak fantasy is the asinine claim that as head of the National Institute of Allergy and Infectious Diseases, Fauci funded research in China that created the pandemic virus and let it loose on the world, and then concealed his complicity. This is a favorite meme among lab-leak fanatics. Among the research bodies that received NIAID funding to conduct field work in China was EcoHealth. (Fauci retired last year as director of NIAID, which is part of the National Institutes of Health.)

On May 1, the GOP-led Select Subcommittee on the Coronavirus Pandemic brought things to a head with its grilling of Daszak. It was a circus featuring posturing politicians intent on smearing Daszak and EcoHealth on the pretext of getting to the bottom of the pandemic’s cause. The committee Democrats participated fully, hammering Daszak as a “poor steward of the taxpayers’ dollars,” based on transparent trivialities.

During a follow-up subcommittee hearing Thursday, ranking member Raul Ruiz (D-Indio) alluded to the dishonestly of the GOP attack on Fauci. But, perhaps inadvertently, he also exposed the dishonesty of his caucus’ attack on Daszak.

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The committee Republicans, Ruiz said, “still have not succeeded in substantiating their allegations that NIH and NIAID through a grant to EcoHealth Alliance created SARS-CoV-2 and conspired to cover it up. … No evidence demonstrates that work performed under the EcoHealth grants, including at the Wuhan Institute of Virology, led to the creation of SARS-CoV-2.”

Does Ruiz ever listen to the words coming out of his mouth? The very goal of the GOP’s dragging Daszak and EcoHealth into this controversy was to fabricate a link in the chain between Fauci and COVID-19; by rejecting the GOP position, Ruiz demolished the case against EcoHealth.

Yet Ruiz didn’t walk the last mile. “EcoHealth has defied its obligations to be a transparent steward of taxpayer dollars,” he said, repeated the lame case against the organization that he first aired, in connivance with the Republicans, during the public interrogation of Daszak on May 1.

Legitimate scientists, such as virology experts uninfected by the conspiratorial fantasy that the virus originated in the lab, are aghast at the suspension of EcoHealth’s funding and the organization’s likely debarment, as well as the Democrats’ supine behavior.

The Democrats, as Stuart Neil, a professor of virology at Kings College London, wrote on X, “have made some shoddy back room deal to allow them to look tough to the conspiracy theorists.” Neil is right. There is no rational explanation for the Democrats’ behavior than some sort of deal with the Republican majority to give them cover to challenge the lab leak theory.

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Put it all together, and it looks like HHS started with a politically driven impulse to cut off EcoHealth’s funding, followed by an effort to assemble every justification for doing so, no matter how trivial. The absurdity of its action drips from the closing words of the notice issued by H. Katrina Brisbon, an HHS “suspension and debarment official.” She wrote that “the immediate suspension of EHA is necessary to protect the public interest and due to a cause of so serious or compelling a nature that it affects EHA’s present responsibility.”

The notice was accompanied by an 11-page bill of particulars, but they all boil down to two key purported offenses — that EcoHealth had missed a 2019 deadline for an annual report of its activities to NIH, and that work EcoHealth had funded in China had produced a recombinant version of a virus that grew fast enough to trigger a safety halt in the work.

The first was tantamount to a traffic violation. EcoHealth maintained that it hadn’t been able to file the report on time because it had been locked out of NIH’s onlline reporting portal, which NIH denies. On the second, there were legitimate disagreements over whether the subject virus’ growth actually did trigger the halt requirement; in any case, the virus wasn’t a threat to human health. The work at issue took place in 2018.

HHS cited several other supposed offenses, including EcoHealth’s failure to submit lab notebooks from the Wuhan institute that NIH has requested in November 2021. But since NIH had ordered EcoHealth to stop funding the institute as of April 2020, those notebooks were plainly out of its reach.

Daszak says EcoHealth will respond to the HHS and the subcommittee “with documentary evidence…refuting every single allegation that’s been levied against us.”

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The roots of anti-science slant of Trump and others on the far right isn’t hard to discern. It’s aimed at protecting the economic establishment from new ideas and realities such as global warming, while providing financial and personal opportunities for grifters and charlatans.

Swiss scientist and science blogger Philipp Markolin has put his finger on this phenomenon.

“Science is a myth-buster,” he writes. “Its debunking activity reduces the value of information products that too many media manipulators rely on for their business. Because of this, science has become a nuisance, even an enemy to some industries and many of the most powerful actors in the new attention economy.”

Why did the Democrats agree to participate in this charade? In joining the Daszak smear, they have shredded their credibility as of scientific truth, at the very moment when science is most in need of their protection.

The time has come to ask this question of Ruiz, his Democratic colleagues on the coronavirus subcommittee — Debbie Dingell of Michigan, Kwesi Mfume of Maryland, Deborah Ross of North Carolina, Robert Garcia of Long Beach, Ami Bera of Sacramento and Jill Tokuda of Hawaii — along with Health and Human Services Secretary Xavier Becerra: How can you live with yourselves?

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Star USC scientist faces scrutiny — retracted papers and a paused drug trial

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Star USC scientist faces scrutiny — retracted papers and a paused drug trial

Late last year, a group of whistleblowers submitted a report to the National Institutes of Health that questioned the integrity of a celebrated USC neuroscientist’s research and the safety of an experimental stroke treatment his company was developing.

NIH has since paused clinical trials for 3K3A-APC, a stroke drug sponsored by ZZ Biotech, a Houston-based company co-founded by Berislav V. Zlokovic, professor and chair of the department of physiology and neuroscience at the Keck School of Medicine of USC.

Three of Zlokovic’s research papers have been retracted by the journal that published them because of problems with their data or images. Journals have issued corrections for seven more papers in which Zlokovic is the only common author, with one receiving a second correction after the new supplied data were found to have problems as well.

For an 11th paper co-authored by Zlokovic the journal Nature Medicine issued an expression of concern, a note journals append to articles when they have reason to believe there may be a problem with the paper but have not conclusively proven so. Since Zlokovic and his co-authors no longer had the original data for one of the questioned figures, the editors wrote, “[r]eaders are therefore alerted to interpret these results with caution.”

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“It’s quite unusual to see this volume of retractions, corrections and expressions of concern, especially in high-tier influential papers,” said Dr. Matthew Schrag, an assistant professor of neurology at Vanderbilt who co-authored the whistleblower report independently of his work at the university.

Both Zlokovic and representatives for USC declined to comment, citing an ongoing review initiated in the wake of the allegations, which were first reported in the journal Science.

“USC takes any allegations of research integrity very seriously,” the university said in a statement. “Consistent with federal regulations and USC policies, this review must be kept confidential.”

Zlokovic “remains committed to cooperating with and respecting that process, although it is unfortunately required due to allegations that are based on incorrect information and faulty premises,” his attorney Alfredo X. Jarrin wrote in an email.

Regarding the articles, “corrections and retractions are a normal and necessary part of the scientific post-publication process,” Jarrin wrote.

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Authors of the whistleblower report and academic integrity experts challenged that assertion.

“If these are honest errors, then the authors should be able to show the actual original data,” said Elisabeth Bik, a microbiologist and scientific integrity consultant who co-wrote the whistleblower report. “It is totally human to make errors, but there are a lot of errors found in these papers. And some of the findings are suggestive of image manipulation.”

Given the staid pace of academic publishing, publishing this many corrections and retractions only a few months after the initial concerns were raised “is, bizarrely, pretty quick,” said Ivan Oransky, co-founder of Retraction Watch.

The whistleblower report submitted to NIH identified allegedly doctored images and data in 35 research papers in which Zlokovic was the sole common author.

“There had been rumblings about things not being reproducible [in Zlokovic’s research] for quite some time,” Schrag said. “The real motivation to speak publicly is that some of his work reached a stage where it was being used to justify clinical trials. And I think that when you have data that may be unreliable as the foundation for that kind of an experiment, the stakes are just so much higher. You’re talking about patients who are often at the most vulnerable medical moment of their life.”

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Over the years, Zlokovic has created several biotech companies aimed at commercializing his scientific work. In 2007, he co-founded ZZ Biotech, which has been working to gain federal approval of 3K3A-APC.

The drug is intended to minimize the bleeding and subsequent brain damage that can occur after an ischemic stroke, in which a blood clot forms in an artery leading to the brain.

In 2022, USC’s Keck School of Medicine received from NIH the first $4 million of a planned $30-million grant to conduct Phase III trials of the experimental stroke treatment on 1,400 people.

In Phase II of the trial, which was published in 2018 and called Rhapsody, six of the 66 patients who received 3K3A-APC died in the first week after their stroke, compared to one person among the 44 patients who got a placebo. Patients who received the drug also tended to report more disability 90 days after their stroke than those who got the placebo. The differences between the two groups were not statistically significant and could have been due to chance, and the death rate for patients in both groups evened out one month after the initial stroke.

“The statements that there is a risk in this trial is false,” said Patrick Lyden, a USC neurologist and stroke expert who was employed by Cedars-Sinai at the time of the trial. Zlokovic worked with Lyden as a co-investigator on the study.

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One correction has been issued to the paper describing the Phase II results, fixing an extra line in a data table that shifted some numbers to the wrong columns. “This mistake is mine. It’s not anybody else’s. I didn’t catch it in multiple readings,” Lyden said, adding that he noticed the error and was already working on the correction when the journal contacted him about it.

He disputed that the trial represented any undue risk to patients.

“I believe it’s safe, especially when you consider that the purpose of Rhapsody was to find a dose — the maximum dose — that was tolerated by the patients without risk, and the Rhapsody trial succeeded in doing that. We did not find any dose that was too high to limit proceeding to Phase III. It’s time to proceed with Phase III.”

Schrag stressed that the whistleblowers did not find evidence of manipulated data in the report from the Phase II trial. But given the errors and alleged data manipulation in Zlokovic’s earlier work, he said, it’s appropriate to scrutinize a clinical trial that would administer the product of his research to people in life-threatening situations.

In the Phase II data, “there’s a coherent pattern of [patient] outcomes trending in the wrong direction. There’s a signal in early mortality … there’s a trend toward worse disability numbers” for patients who received the drug instead of a placebo, he said.

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None are “conclusive proof of harm,” he said. But “when you’re seeing a red flag or a trend in the clinical trial, I would tend to give that more weight in the setting of serious ethical concerns around the pre-clinical data.”

The NIH paused the clinical trial in November, and it remains on hold, said Dr. Pooja Khatr, principal investigator of the NIH StrokeNet National Coordinating Center. Khatr declined to comment on the pause or the trial’s future, referring further questions to USC and NIH.

The NIH Office of Extramural Research declined to discuss Rhapsody or Zlokovic, citing confidentiality regarding grant deliberations.

ZZ Biotech Chief Executive Kent Pryor, who in 2022 called the drug “a potential game-changer,” said he had no comment or information on the halted trial.

Zlokovic is a leading researcher on the blood-brain barrier, with particular interest in its role in stroke and dementia. He received his medical degree and doctorate in physiology at the University of Belgrade and joined the faculty at USC’s Keck School of Medicine after several fellowships in London. A polyglot and amateur opera singer, Zlokovic left USC and spent 11 years at the University of Rochester before returning in 2011. He was appointed director of USC’s Zilkha Neurogenetic Institute the following year.

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A USC spokesperson confirmed that Zlokovic has retained his titles as department chair and director of the Zilkha institute.

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What military doctors can teach us about power in the United States

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What military doctors can teach us about power in the United States

Power is invisible, but its effects can be seen everywhere — especially in the health records of active duty military personnel.

By examining details of 1.5 million emergency room visits at U.S. military hospitals nationwide, researchers found that doctors invested significantly more resources in patients who outranked them than in patients of equal or lesser rank. The additional clinical effort devoted to powerful patients came at the expense of junior patients, who received worse care and were more likely to become seriously ill.

Military rank wasn’t the only form of power that translated into inequitable treatment. The researchers documented that patients fared better when they shared the same race or gender as their doctor, a pattern that tended to favor white men and caused Black patients in particular to be shortchanged by their physicians.

The results were published Thursday in the journal Science.

The findings have implications far beyond the realm of the military, said Manasvini Singh, a health and behavioral economist at Carnegie Mellon University who conducted the research with Stephen D. Schwab, an organizational health economist at the University of Texas at San Antonio.

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For instance, they can help explain why Black students do better in school when they are taught by Black teachers, and why Black defendants get more even-handed treatment from Black judges.

“We think our results speak to many settings,” Singh said.

The disparities wrought by power imbalances are easy to spot but difficult to study in real-world scenarios.

“It’s just hard to measure power,” Singh said. “It’s abstract, it’s complicated.”

That’s where the military health records come in.

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The Military Health System operates 51 hospitals across the country. The doctors who staff them are active-duty personnel, as are many of the patients they treat. Comparing their ranks gave Singh and Schwab a handy way to gauge the power differential between physicians and the people in their care.

The researchers restricted their analysis to patients who sought treatment in emergency departments, where patients are randomly assigned to doctors. That randomness made it easier to measure how power influenced the treatment patients received.

To further isolate the effects of power, the researchers made comparisons between patients of the same rank. If they happened to outrank their doctor, they were considered a “high-power” patient. If not, they were classified as a “low-power” patient.

The medical records showed that doctors put 3.6% more effort into treating high-power patients than low-power ones. They also utilized significantly more resources such as clinical tests, scans and procedures, according to the study.

Those extra resources translated into better care: High-power patients were 15% less likely to become sick enough to be admitted to the hospital over the next 30 days.

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To see if they could replicate their results, Singh and Schwab narrowed their focus to doctors who treated patients within a one-year period before or after the patients were promoted to a higher rank. The researchers found that doctors devoted 1% more effort to patients post-promotion, as well as more medical resources. Those differences may have been small, but they were statistically significant, Schwab said.

Next, the pair considered what happened to low-power patients while high-power patients were getting extra attention. One hypothesis was that ordering additional tests for one patient might prompt doctors to order the same tests for everyone they treated that day. It was also possible that the decisions doctors made for their high-power patients had no bearing on their other patients.

Neither turned out to be the case. Instead, the added effort spent on high-power patients was siphoned away from low-power patients, who got 1.9% less effort from their doctors. On top of that, their risk of needing to return to the ER or be admitted to the hospital over the following 30 days increased by 3.4%, the researchers found.

“The powerful unwittingly ‘steal’ resources from less-powerful individuals,” Schwab and Singh wrote.

Outside the military, doctors and patients can’t use official rank to measure their power relative to each other, but they do contend with the effects of race and gender. That led the researchers to investigate whether the physicians in their study treated patients differently if they shared these attributes.

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White doctors devoted more effort to white patients than to Black patients across the board, the researchers found. The gap was the same regardless of whether the doctor had a higher or lower rank than the patient.

However, white doctors increased their effort for high-power patients by the same amount regardless of race. As a result, white doctors treated high-power Black patients the same, on average, as low-power white patients.

The story was different for Black doctors. When they outranked their patients, they gave essentially the same amount of effort to everyone. But on the rare occasions when they encountered a higher-ranked Black patient, the amount by which they dialed up their efforts was more than 17 times greater than it was when they treated a higher-ranked white patient.

It’s not clear what accounted for this “off-the-charts effort,” the researchers wrote. They speculated that since Black service members were underrepresented among the pool of high-power patients, Black doctors were particularly attuned to their status.

The effects of gender were more difficult to ascertain, since biology dictates that men and women require different kinds of care.

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Both male and female doctors invested the most effort in female patients who outranked them. But male doctors upgraded their care for high-power patients of both genders to a much greater extent than female doctors. And unlike female doctors, male doctors devoted more effort to female patients across the board.

Finally, the researchers wondered whether doctors gave preferential treatment to high-power patients because of their elevated status or because those patients had the authority to make trouble if they were unsatisfied with their care. To make inferences about this, they compared the treatment of retirees (who retained their status but had given up their authority) to the treatment of active-duty patients (who still had both).

Schwab and Singh found that high-power patients continued to elicit extra effort from doctors for up to five years after they retired, suggesting that status was an important factor.

“I think it’s really, really cool that even after retirement, you still have these effects,” said Joe C. Magee, a professor of management and organization at the NYU Stern School of Business who studies the role of hierarchy. He sees that as a strong sign that status was driving doctors’ decisions all along.

“What these folks are able to show is that it has real health consequences,” Magee said.

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Eric Anicich, a professor of management and organization at the USC Marshall School of Business, called the study “impressive” and the findings “important.”

Although a 3.5% increase or a 1.9% decrease in physician effort may seem small, their cumulative impact is meaningful, especially when it comes to something as critically important as healthcare, he said.

The inequities documented in the study aren’t unique to doctors or to the armed forces, Schwab and Singh said. The mathematical model they developed to describe the behavior in military emergency rooms also helps explain why people in all kinds of situations give preferential treatment to people who look like them: It may help minimize the effects of societal disparities.

In a commentary that accompanies the study, Laura Nimmon of the University of British Columbia’s Centre for Health Education Scholarship wrote that “the ephemeral and unobservable nature of power has made it profoundly difficult to study.” But she said it’s worth the effort to make sure doctors wield their power more fairly.

The disparities reported by Schwab and Singh are “of serious concern to society at large,” she wrote.

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